Fillable Form Ipf-1 - Individual Premium Finance License Application printable pdf download

Form Ipf-1 - Individual Premium Finance License Application

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Illinois Department of Financial and Professional Regulation

Division of Insurance

320 W. Washington Street

Springfield, IL 62767-0001

Individual Premium Finance License Application–IPF–1

Fee Requirement: Attach a check or money order payable to the Director of Insurance for $400.

License will expire one year following date of issue.

Name of Applicant (print or type)

Social Security #

Resident Address (Number and Street)

Room #

City

State

Zip Code

Assumed name(S) under which you do business (DBA)

Telephone # (include area code)

Yes

√

1. Have you, within the past three (3) years, been found guilty of a felony? If “yes,’’ attach (1) a statement from your probation officer;

(2) certified copies of the indictment, judgement and sentencing order.

2. Have you ever been refused a license to act as a premium finance company, agent, broker, producer or solicitor, or has a license

to act as such ever been denied, suspended, revoked or surrendered for disciplinary reasons in any state either as an individual or

as a member of a firm? If “yes,’’ attach a copy of the order or other applicable documents.

3. Does the applicant have a license to engage in business as an insurance producer?

Declaration and Certifications

I certify that no charge for financing premiums shall exceed the rates permitted under Section 513a10 of Article XXXIIA.

I further certify that the premium finance agreement or other forms being used are in compliance with the requirements

of Section 513a9 of Article XXXIIA.

I further certify that I have a minimum net worth of $50,000.

I, the undersigned, declare under penalties of revocation or refusal of license that the statements made in this applica-

tion are true, correct and complete to the best of my knowledge and belief.

Signature of Applicant

Date

Important Notice: Disclosure of this information is required under the Illinois Revised Statutes’ insurance laws. Failure to provide this information will

result in this form not being processed. This form has been approved by the Forms Management Center.

IL446–0183

Revised 07/04

Printed on recycled paper.